HomeMy WebLinkAbout520 Kim Dr - Special Inspections/Combustion Safety - 03/17/2014Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliance
Address: .6-7-p jl",�rmit Number: 40 L ^ o
Contractor/Agency: dz (.Equipment Replaced: A/,ATdr/1 L��A'T�iQ
Natural Conditions: Pass ✓ Fail Date Tested 7 Z11
(Failed test requires corrections until Natural Conditions test passes.)
Worst Case Conditions: Pass Fail Date Tested
Failed appliance information:
(Failed test requires owner's signature acknowledging results.)
I certify that I am the legal owner of the above listed property and hereby acknowledge that my
appliance has failed a Combustion Safety Test under worst -case conditions.
Owner's Name (print) 6
Owner's Signature
Date
(One form submitted to Building Services department; duplicate form given to property owner)